Consent and Payment Form

(To be accompanied by a referral form)

Patient Information

Laboratory testing

The presence or absence of a specific gene mutation has been identified as a predictor of drug response. Testing for gene mutations prior to treatment ensures that the patient receives a drug that has the potential to work for them.

***Patient Consent***

I understand that laboratory testing on my tissue is part of a clinical workup for my condition and the testing to be undertaken has been explained to me by the requesting clinician. I give permission for my tissue to be used for the following laboratory tests(s):

Payment Required *

Samples will not be processed unless payment has been confirmed.

*This is the current cost of testing for the panels listed above ONLY. Please contact the laboratory for the cost of any “other” tests required.